Hamish, MD
by Rosabell
Summary: John Watson might not be a genius like Sherlock Holmes, but his line of work is not one for the weak-minded, and there were plenty of times when Sherlock was baffled by John's insight. Especially when John fired off those (almost) zero-punctuation dictations.


"Letter dictation to Dr. Brown address 408 South Street—Dear Dr. Brown I would like to introduce to you a case of Mr. Bill Jones period. He is a fifty-five-year-old male with multiple medical problems including insulin-dependent diabetes comma hypertension, comma hyperlipidemia comma and mild COPD period. He has a thirty-six pack year history of smoking period. He has no past surgical history period. He has come to me for his umbilical hernia comma which he has noticed for"—he checked his notes to confirm—"the past five months period. CT images show a one point five-centimeter in diameter defect in the abdominal wall with reducible protrusion of fat but no evidence of bowel or strangulation period." John glanced down at his notes for a moment. "In addition CT images show no evidence of masses or tumors period. Besides aesthetic complaints comma Mr. Jones has no other symptoms from his hernia, period. I have discussed with Mr. Jones the need for a workup and would like for you to see him and determine if surgical repair is indicated."

He broke off from his dictation to glance at his patient, who was gobsmacked at his rapid and concise delivery. "Can you see Dr. Brown in two weeks?"

"…I guess?"

"Okay." John turned back to his dictation. "Period paragraph I have discussed with Mr. Jones about seeing you period. I look forward to hearing your opinions period. Yours truly John Watson."

He hung up the phone and turned to Jones, his speech now normal. "So, there we go. I let Dr. Brown know. It's very important that you follow-up on the colonoscopy, as I said before. CT images are good at detecting a lot of things, but you need a colonoscopy to rule out colon cancer."

"…yes sir," Jones nodded, troubled.

"Very good," John patted his shoulder, "Don't worry about the worst-case scenario for now. Plenty of patients come in here with umbilical hernias. We make a point of screening for cancer but there's a good percentage of them who don't have anything wrong, other than the defect itself. It's just better safe than sorry, you know?"

"Yes Doctor," Jones managed a smile. "Thanks a lot.

"Very good. Dr. Brown will receive the letter and should know the story. Alright?"

His phone buzzed, signaling a text. John ignored it to see Jones out, before ducking back and looking to see who it was.

_-Case. Twins murdered. Meet me at the fountain in ten. SH-_

John glanced up at the clock. Technically, his schedule only spanned until five, but as was often the case in clinics, he was running late. Sherlock probably thought he had left already. Right now it was ten after five, but he still had three patients to see.

_-Can't. 3 patients left. Might not be done until 6. JW-_

Sherlock was likely to be annoyed, but at least in this case, he had never given John too much of a hard time when he was late from clinic.

_-I'll text when I'm done. JW-_

No response from Sherlock, but John was not expecting one. He picked up a patient's folder and looked at the name. Marian Willis. He had seen her before: thirty-six years old, myasthenia gravis; a odd age of onset because usually the illness manifested at ages 50 and 60, and in males. She had presented ambiguously too; instead of the usual diplopia (double-vision) and ptosis (droopy eyelid), she just "felt tired". John looked tested for fatigue with eye elevation purely on a hunch, since he was use to medicine not following textbooks. She did start having diplopia and a noticeable strabismus after about ten seconds, which resolved with ice pack. Radiographs afterwards showed a giant thymoma. Thymectomy, and that was that. Or should have been, because generally the thymus should not grow back once it was removed. John frowned, hoping that she was not here for the same thing again, because that would mean the thymoma was not completely removed during her surgery. He was not sure whether he should breathe a sigh of relief or groan when he saw that the chief complaint was "breast lump".

_Probably a simple cyst. Do I even need to see her?_ He sighed again. For all he knew, Willis could be here for a legitimate malignancy. Breast cancer in thirty-year-olds is not unheard of. It was just…unlikely, and given her age, a mammography would be totally useless.

"Hey John, " Sarah tapped him on the shoulder before he could go to the room, "can you look in on a patient for me?"

"Sure. What's going on?"

"Fifteen-year-old male, African, sickle cell trait and no other medical conditions, came in for a well-child checkup. No abdominal pain, but there's this firmness that's kind of square in shape on his belly on physical exam."

_Sickle-cell trait. No chance of crisis, then._ "Bowel movements?"

"He said he _felt_ constipated; last bowel movement was this morning, so it could just be stool, but I'm not sure. It's just so bizarre. No tenderness to palpation, no melena or hemachezia, no diarrhea, no recent weight loss. No family history of cancer or GI problems. Can you just take a feel for me? I'm trying to figure out whether I want to order an abdominal X-ray."

"In a fifteen-year-old? And no tenderness or abdominal pain?"

"No. Can you take a look?"

"…Sure. Name?"

"Adam Smith."

Adam Smith was a gangly teenager, quite tall for his age and on the cusp of his growth spurt. He had an adorable little sister, four years in age, and who kept reaching up to John for him to pick her up. He indulged her briefly, since Adam looked comfortable, sitting upright on the exam table.

Sarah had already palpated his belly, which would normally silence the intestines, but John took off his stethoscope anyway to listen for bowel sounds. It was quiet, but not silent, which was about what he would expect.

"Last time you had a number two was this morning?"

"Yeah," the boy said shyly.

"Any blood?"

"I didn't see it. It wasn't black either," he added, anticipating the question. "It was hard, kind of pebbly, I guess."

"Alright. Lie back," and when the boy did so, John started to feel as he asked, "What do you normally eat?"

"I don't know. Chicken. rice. Beans. Your usual."

"You eat your vegetables, mate?"

Adam twisted his lip.

"I keep trying to get him to," the mother lamented, "but you know teenagers. Stubborn."

"They're not my favourite either," John told Adam. He did not mind the stuff, but he never loved them either. "But you're really constipated."

"Stool?" Sarah asked.

"More likely. I wouldn't do a CT, would just follow-up and see if there's any change," John nodded. He withdrew his hand; he never asked his patients "does it hurt when I press", the way medical students and residents did; certain patients would always say yes, so it was not helpful. People would wince and complain if it hurt, without prompting. "You need to have some fiber in your diet, my man, or else you'll be carrying a ton of poop in ye and it will go all the way up to here"—he gestured up to his throat—"You want that?"

Adam was grinning, white teeth bright against his relatively dark skin. "No," he replied, laughing a little.

John left Sarah to consult the boy and his mom, with one more hug for the little girl. He was heading to the room to see Willis when a nurse grabbed him.

"Dr. Patel is on the phone for you."

"Which Dr. Patel?"

"Cardiology."

"…Which Dr. Patel?" There were plenty of cardiologist Dr. Patels.

"I don't know. He's asking about a patient, Michael Morris?"

John blinked. The name was familiar, and he remembered the drugs Morris was prescribed, but he could not remember the man himself. Sighing as he glanced at the patient chart, he went to the phone.

"Hello, this is Dr. Watson."

_"Hello Dr. Watson, this is Dr. Patel from Goldstein Cardiology Associates. I'm calling about a patient named Michael Morris, forty-three-year-old with stage three heart failure and diabetes. He said that you didn't put him on an ACE inhibitor or an ARB, but he couldn't recall the reason why. I'm trying to confirm that he really can't take them; he's not really a good historian."_

"Oh." John held the phone between his ear and shoulder so his hands were free to log in to the computer to look at the electronic medical record. "I remember he had hypersensitivity reaction to lisinopril." It never ceased to astound him, the kinds of things patients were capable of forgetting.

_"Was that what it was?"_

"Uh-huh…angioedema back in 2004 per his previous GP. I did prescribe Cozaar." Seriously, the kinds of things patients forget. _He's kept his blood glucose under control, at least. Renal function in the last checkup was normal, no microalbuminuria. When's his next appointment?_

_"Thanks a lot, Dr. Watson,"_ said Patel, _"Just checking to make sure. If he's on Cozaar already I'll just leave him on it."_

Normally, John would ask for more updates over the phone, but it was already 5:45 and he really had to get going. "No problem. Thanks for calling."

His phone vibrated, and John look at it more to make sure it was not another physician than to see what Sherlock had to say, even though it did turn out to be Sherlock.

_-Are you still at the clinic? SH-_

Ugh, John groaned mentally. _-Unfortunately. Three patients left still, very behind. Might not be able to join you for this one. JW-_

No response again.

_Whatever. Willis is in room 6._

Marian Willis was a comely brunette with tight ringlet curls and a thin frame. She shook John's hand with dry, cold fingers and sat on the examination table with her purse in her lap, wearing a t-shirt and jeans.

_Damn it,_ John swore mentally, _what part of 'breast lump' did they miss?_ "You can leave that on the chair," John gestured. She laughed as she got down to do just that. "I'll ask questions first but if this is about a breast lump, you really should be in a gown."

"Oh," she looked dismayed.

"It's not your fault. Must have slipped the nurse's mind." He took a seat. "Tell me about this. Where and when did you notice it?"

"On my right," she gestured vaguely with her left fist, which was loosely flexed. "I noticed it three days ago and called the office. It doesn't hurt but once I realized it was there, I keep noticing it. It's like the size of my pinky-nail."

"Any skin changes over it?"

"…no."

"Any recent weight-loss?"

"…Not that I've noticed. I do feel more tired lately, but it could just be because of my job; we have a new manager and she's really really uptight."

"That's rough," John said sympathetically and looked in her chart again. "Other than the thymectomy, any other surgical procedures?"

"No."

"Family history of breast cancer?"

"My mom's cousin had breast cancer, but otherwise no one else does."

"Do you take birth control pills?"

"Yeah…" Willis looked worried, "did that cause the lump?"

"Hard to say. I ask everyone, different studies have said different things so," John checked off a box, "it doesn't mean anything in the long-run. It may or may not be a risk-factor. Do you smoke?"

"No."

"Ever smoked?"

"No." This inspired a grin.

"Okay," John opened a cabinet and handed her a gown, "I'll be right back while you change into that, alright?"

"Sure, Doctor."

He went out to find another doctor, Fred Price, wrestling with the door to the procedure room.

"We really need to get a new door," he complained as John walked by. "I'm entering the combination and it's reading it, but the handle's stuck."

John spent about five minutes getting the door open for Fred. He headed back to Willis' room at around six.

"Sorry for that," he apologized, "let's take a look."

He zeroed in on the right breast. The lump was not difficult to palpate; right on the superior-lateral quadrant, the size of a pinky nail, hard as stone and unmovable.

_God damn it._

"Raise your arm above your head," he instructed, feeling the axilla. Nothing, though that could be anything. He felt above her clavicle. "Cough for me, please? Good." Nothing either. Not that Willis could use any more bad news.

"You're right," he said to Willis after he was certain he could not feel any lymph nodes. "I am concerned about this as well. No one else in your family had breast cancer?"

She shook her head, mute and troubled.

"A tumor is part of the differential, unfortunately." John told her. "The good news is, I don't feel any lymph nodes. I'm going to refer you to a breast surgeon for them to decide how to best approach this. Very likely they will do a biopsy to figure out what it is—"

Her eyes grew glassy, so John gave up giving her more information in favor of passing her some tissues. "I know this is hard to hear. You've been through a rough time—"

"I don't want any more surgeries!" she whimpered as a tear escaped from one eye. "The last one took me forever to recover from—"

"I know. It's a major procedure, it's normal to feel scared. You've been through a lot, and tumors are a big deal."

* * *

At 19:00, Willis left the clinic in relatively lighter spirits, while John was about ready to cry himself. He looked at the remaining charts. One person was coming in with depression, and another one was coming in to get a form filled out. Even though the latter was supposed to be later, John selected him first.

"Thanks, doc," said the man, as John quickly reviewed his chart before signing the forms. "Jesus, it's a long day for you today."

"You're telling me," John gave the forms to him, and tried not to be too obvious that he was shooing the man out the door.

At 19:07, John called in the last patient: Miranda Warner. By that point, the surgery was entirely empty except for the two of them.

"You were prescribed Prozac two weeks ago," he noted, "it takes a while for them to work, you know." _I thought I went over this with you…?_ "It can take up to eight weeks."

"…oh."

"Have you missed any doses?"

"Once or twice."

John tried not to grimace. He had often complained about how illogical it was to expect someone with a psychiatric problem to behave rationally and responsibly.

"It's very important that you take these things religiously," he told Warner, "missing a dose can increase your risk of another episode."

She nodded, looking guilty. John decided to just check that off the list.

"Is there something that prevents you from taking them?"

"…I guess I just forget, sometimes…"

"Is there some way for you to remember better? Maybe put them next to your toothbrush?" It was a common tip gynecologists used when prescribing oral contraceptives. "That way, when you go brush your teeth, it's right there, and you just take it."

"I guess I can do that."

"Okay? Good. Have you thought that maybe the world is better off without you?" he asked, probing gently for any thoughts of suicide and really hoping that the answer was negative.

"Well," Warner replied tremulously, "I felt like hanging myself yesterday…"

_Oh **God**._

* * *

John left the office at 21:00 and arrived home at 21:30. Sherlock did not even glance up from his laptop. His, as in John's.

"You're late," he said in a dry, almost disinterested voice.

"Yeah well, forgive me for stopping someone from committing suicide." Convincing Warner to go with the techs and admit herself to the wards voluntarily had been very taxing, and John was so tired that he was not even hungry. "That, and telling a patient that she has breast cancer and might lose a breast." It was seriously just his luck that all the drama tends to happen at the end of the day, when everyone was tired and very ready to go home.

"Boring," Sherlock said flatly. "Medicine is a complete waste of your talents."

John ignored him. Sherlock probably meant it as a compliment; only he would think that medicine was a waste of time.


End file.
